Paederus dermatitis in Najaf province of Iraq Muhsin A. Al-Dhalimi, MD, CAB (Derm). ABSTRACT presentation comprised geographic and linear erythematous plaques with micropustules. Kissing lesions were seen in 5.7% of cases. Periorbital اﻷهداف: محاولة تقييم مختلف املظاهر الوبائية و السريرية .involvement was recorded in 16.1% of the cases ﻻلتهاب اجللد اخلنفسائي في محافظة النجف. Conclusion: Paederus dermatitis is a common skin condition in Najaf province. The awareness of this الطريقة: أجريت دراسة رصدية مسستقبلية تضمنت التقييم condition among the medical practitioners will السريري لـ87 ً مريضايعانون من تشخيص نهائي بالتهاب اجللد aid in the early diagnosis and prompt treatment of اخلنفسائي، واللذين قدموا إلى عيادة اﻷمراض اجللدية في محافظة the disease. Also, overall public awareness can help النجف – العراق، خﻻل الفترة مابني ابريل 2006م وحتى ابريل .decrease the incidence of Paederus dermatitis 2007م. Saudi Med J 2008; Vol. 29 (10): 1490-1493 النتائج: إن وقت الذروة للمرض كان في شهر مايو، أكثر اﻷماكن From the Department of Dermatology, College of Medicine, University of تأثرا ًباﻹصابة هي الوجه والعنق. وكان املظهر املخيف لﻵفه هو Kufa, Iraq. السبب الرئيسي في مراجعة املرضى للمستشفى. أعراض احلرق .Received 7th July 2008. Accepted 14th September 2008 واللسع كانت بدرجة معتدلة ًسريريا. أكثر اﻷنواع شيوعا هي .Address correspondence and reprint request to: Professor Muhsin A اخلطية واجلغرافية وتضم لويحات حمامية مع بثور تقيحية .Al-Dhalimi, PO Box 591, Najaf, Iraq. Tel. +964 (78)1241806. Fax صغيرة. ولوحظت اﻵفات املتقابلة في %5.7 من احلاﻻت، E-mail: [email protected] .3368245 (3) 964+ وتأثرت املنطقة ما حول العني في %16.1 من احلاﻻت. aederus dermatitis (PD) is a peculiar type of acute خامتة: التهاب اجللد اخلنفسائي هو حالة مرضية موجودة في Pirritant contact dermatitis attributed to Staphylinidae محافظة النجف. الوعي بهذه احلالة بني اﻷطباء املمارسني سوف beetle of genus paederus.1 It is characterized by the تساعد في التشخيص املبكر والعﻻج الفوري. كما أن الوعي sudden onset of stinging or burning sensation with العام عموما ميكن أن يساعد في انخفاض معدل اﻹصابة بهذه appearance of vesicles and pustules on erythematous احلالة املرضية. base. It usually takes a linear (dermatitis linearis), or Objective: To assess the different epidemiological bizarre geographical shape.2 Paederus dermatitis usually and clinical features of Paederus dermatitis in Najaf province. affects the exposed parts of the body. This comes from a beetle that does not bite or sting, but accidental brushing Method: This prospective observational study, against or crushing it over the skin provokes the release including the clinical assessment of 87 patients of a vesicant chemical pederin, which is contained in the with definitive diagnosis of Paederus dermatitis, body fluid of the beetle.3,4 We noticed annual outbreaks who presented to a dermatology clinic in the Najaf of PD in Najaf province, which is located in the middle province of Iraq, was carried out from April 2006 to Euphrates region of Iraq, in the last few years. Although April 2007. many studies have been carried out about outbreaks of PD in various countries from different areas of the Results: The peak time of presentation was in May, world like Iran,5 Sri Lanka,6 Tanzania,7,8 Nigeria,9,10 and the face and neck were the most common sites Turkey,11,12 Australia,13,14 India,15,16 Peru,17 Pakistan,18 of involvement. Frightening appearance of the lesion 19 20 is the main cause that brought the patients to the Brazil, and Sierra Leone. No previous study about hospital. The symptoms of burning and stinging PD was carried out in Iraq. The aim of this work was to were of mild degree. Clinically, the most common evaluate the clinical and epidemiological aspects of PD in Najaf province. 1490 20Paederus20080662.indd 1490 10/20/08 2:50:26 PM Paederus dermatitis in Najaf province … Al-Dhalimi Methods. This observational prospective study was the definite history of contact with the beetle. Of the conducted in the outpatient dermatology clinic in Al- remaining patients, 53 (73.6%) confirmed the presence Sadr Teaching Hospital, Najaf during a one-year period of the beetle in their surroundings. Most of the patients from April 2006 to April 2007. The diagnosis was notice the lesions when they wake up in the morning mainly clinical depending on previous experience with after the previous night contact with the beetle. The this condition. The study included patients with typical lesions presented as erythematous plaques studded history of sudden onset of vesicant dermatitis, with with vesicles and micropustules (Figure 1). The erosions or without slight burning or stinging sensation, often due to ruptured vesicles are more prominent in older occurred at night, and the lesions started to appear the lesions. The lesions were linear in 51 (58.6%) lesions, next morning. The examination of the lesions revealed special railroad like appearance was noticed in 6 of these typical linear or bizarre shaped contact dermatitis-like linear lesions (Figure 2). About 85% of the linear lesions lesions. Patients with typical lesions from affected areas were located on the face and neck. Irregular rounded or with definite history of contact with insect were also geographical lesions were present in 36 (41.4%) cases. included. Patients with other possible causes of contact Kissing lesions (Figure 3) were noticed in 5 (5.7%) dermatitis, and those with chronic skin problems were patients especially on the axillae and antecubital fossae. excluded from the study. A detailed history was taken The latter type of the shape of the lesion was found on regarding the age, gender, duration of the condition, the trunk and proximal extremities in 29 (80.5%) cases. the chief complaint, associated symptoms, and Single lesion was present in 31(35.6%) patients, while residency. The morphology, number and location of multiple lesions were found in 56 (64.4%). The most the lesions were assessed on physical examination. The common sites of involvement in descending order of study follows the ethical and scientific rules of the local frequency were the neck in 35 (40.2%) cases, face in scientific committee. 30 (34.4%), extremities in 27 (31%), and the trunk in 15 (17.2%) cases. Periorbital involvement was noticed Results. The total number of the patients was 87, 54 in 14 (16.1%) cases (Figure 2). Some patients with (62%) patients were males, and 33 (38%) were females. The age of the patients ranged from 4 months to 50 years (mean age 21.3±11.6 years, median age 22 years). The duration of the lesions from the time of the onset of the disease varied from 1-7 days (mean 2.3±1.7 days, median 2 days). The most recorded chief complaint was the frightening sudden appearance of the lesions in 74 (85%) patients. On further questioning, burning sensation was found in 55 (63.2%) patients, itching in 15 (17.2%), pain in 4 (4.6%) patients, and 13 (14.9%) patients were asymptomatic. Thirty-two (36.8%) patients were from urban areas, while 55 (63.2%) were from rural areas. Only 15 (17.2%) of the patients gave Figure 2 - Paederus dermatitis presented on the face, presented as 3 linear lesions with concomitant ipsilateral periocular involvement resulting from spread of pederin to the eyelids by the hands. Figure 1 - Paederus dermatitis presented as acute onset ill defined Figure 3 - Kissing lesions on the axilla studded with pustules and erythematous lesion studded with many micropustules on the vesicles often seen from the spread of pederin to adjacent skin neck. surfaces. www. smj.org.sa Saudi Med J 2008; Vol. 29 (10) 1491 20Paederus20080662.indd 1491 10/20/08 2:50:27 PM Paederus dermatitis in Najaf province … Al-Dhalimi multiple lesions have more than one site of involvement. Najaf region. With the poor supply of the electricity in The peak incidence of onset and presentation of PD the last years due to sanction that increased after the was in the month of May in 46 (52.8%) patients. United States invasion of Iraq, residents spend their The other cases were presented in the months of June evenings and nights in the gardens of their homes and in 28 (32.2%), April in 6 (6.9%), July in 5 (5.7%), in the streets. For an even cooler place, residents often and August in 2 (2.3%). No case was recorded in any sleep on the roof. Under these circumstances, most cases other months of the year. Most of the lesions disappear are probably not caused by the intentional crushing of spontaneously in 1-2 weeks leaving a mild and transient the beetle, rather the extensive presence of these beetles hyper-pigmentation without scarring. in the environment makes accidental exposure difficult to avoid. Crushing Paederus beetles on the skin has no Discussion. Paederus dermatitis is the result of immediate effect, however, acute dermatitis appears mucocutaneous contact of the members of the genus 12-36 hours later.15 This explains why most of our Paederus that contain pederin, a potent vesicant agent 3 patients notice the appearance of the lesions during the contained in the body fluids of the beetle. While, the day time, after a night contact with the beetle. Paederus vesicant chemical in both Oedemeridae and Meloidae dermatitis occurs predominantly on exposed parts of is cantharidin. The clinicopathologic picture differs the body. The face and neck were found to be the most depending on the vesicant agent. Cantharidin dermatitis commonly involved sites in the previous studies,5,6,10,1 is characterized by noninflammatory vesicles or bullae, 2,15,16,18,20 Our study also found this type of dermatitis whereas PD is characterized by vesicles and pustules 1-3 more commonly over the uncovered parts of the body, arising from intensely inflamed skin.